Provider Demographics
NPI:1376181057
Name:DAVIS, GRACE ELLEN (APRN)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:ELLEN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2984 S RIDGEWOOD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32141-7515
Mailing Address - Country:US
Mailing Address - Phone:386-428-4640
Mailing Address - Fax:
Practice Address - Street 1:2984 S RIDGEWOOD AVE STE A
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32141-7515
Practice Address - Country:US
Practice Address - Phone:386-428-4640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-13
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC236330163WE0003X
FL11004464363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency